Objective
To track trends in copay rates for high-value services.
Research Question
Copay rates have been rising for services important for chronic-disease management.
Study Design
We will identify patients suffering from chronic diseases such as diabetes, congestive heart failure, coronary artery disease (post AMI), asthma, and depression. We will add a final category of “prevention” for services applicable to populations without identified disease. The prevention cohort will be identified using age and gender data and the appropriate clinical guidelines. In each case, patient cohorts will be defined for 2000 and 2005 based on claims data. Where possible, we will define the cohorts using HEDIS criteria (which are commonly used for pay-for-performance [P4P] programs). Otherwise, our basic rule will be that patients qualify for the cohort if they have two outpatient or one inpatient visit with the relevant primary or secondary diagnosis codes.
Within each disease cohort, we will define several sets of important services, including pharmaceuticals and nonpharmaceutical services. These services will be selected based on clinical guidelines and their inclusion in quality- improvement programs such as P4P programs and disease-management programs. We will compute average patient out-of-pocket costs for the services within each cohort for 2000 and 2005. This cost will reflect copays, deductibles, and coinsurance rates.
We will compare these trends to aggregate copay trends for high-value services with trends for the same services in the general population (excluding the sample of people for whom we determined these services to be of high value), to make the point that patients who have a high need for specific services are charged as much as patients who have a lesser need. We will also compare these trends with out-of-pocket cost-sharing trends for all prescription medications and for other services thought to be of lesser value. We have not yet defined these comparison services, but they may include more controversial tests (such as PSA tests) or more controversial medications (such as selected lifestyle medications).
